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Key messages from the report

The report contains the following key messages
and recommendations:

Developments in engineering and health indicate
the potential benefits of using a 'systems
approach' to understanding frontline practice
in order to improve the quality and safety of
service provision.

This report and the accompanying guide
presents an adapted systems model for multi-agency
safeguarding and child protection work.

It is an innovative approach that requires
a respectful approach towards the practice experience
of street-level workers and their managers.

It involves moving beyond the basic facts of
a case chronology and appreciating the differing
views that different workers had at the time.

The aim is to identify underlying patterns
of factors in the work environment that support
good practice or create unsafe conditions in
which poor practice is more likely.

This kind of organisational learning is vital
to improving the quality of services provision
and needs to be applied to ordinary work, not
just to tragedies.

Context

Children's safety and welfare are
key concerns in all countries, with continual efforts
being made to improve child welfare and child protection
services. Learning is central to these endeavours
so that problems and their solutions can be identified.
However, it has been questioned as to whether current
learning approaches are adequate for the task. In
light of this, SCIE presents a 'systems' model
of organisational learning that can be used across
agencies involved in safeguarding and child protection
work.

Purpose

The findings of serious case reviews (SCRs)
and public inquiries tend to be familiar and repetitive,
raising questions about their value for improving
practice. Similar circumstances in engineering,
health and other high-risk industries led to
the development of the 'systems approach' -
this gets to the bottom of why accidents occur
and so allows for more effective solutions.
It is a method for identifying what works well
as well as where there are problems. Academics
have demonstrated that the approach also works
for the field of safeguarding and protecting children
in theory, which is the basis for this report. To
work in practice, the approach needed to be tested
out and adapted. The aim is to 'make it harder
for people to do something wrong and easier for
them to do it right' (Institute of Medicine,
1999: 2)

Audience

The systems model can be applied to serious
case reviews (SCRs). It also has particular value
in times of major change in services delivery,
when it can be used to understand progress on
the implementation of new working practices and
accompanying tools such as the Common Assessment
Framework (CAF). It will therefore be
useful for both frontline staff and senior management. The
model is collaborative and encourages joint working.

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